Study finds evidence of racial, class discrimination among psychotherapists

"Although I expected to find racial and class-based disparities, the magnitude of the discrimination working-class therapy seekers faced exceeded my grimmest expectations," said Heather Kugelmass, a doctoral student in sociology at Princeton University and the author of the study.

Among middle-class people who contacted a therapist to schedule an appointment, Kugelmass found that 28 percent of whites and 17 percent of blacks received appointment offers. Appointment offer rates for both black and white working-class therapy seekers were 8 percent.

"The fact that this study uncovers discrimination in the private mental health care marketplace is consistent with previous audit studies that have revealed discrimination in other marketplaces, such as housing and employment," said Kugelmass, who noted that her research provides insight into ordinarily private exchanges that may subtly perpetuate disadvantage.

Titled, "'Sorry, I'm Not Accepting New Patients': An Audit Study of Access to Mental Health Care," the study appears in the June issue of the Journal of Health and Social Behavior. As part of this study, 320 New York City-based psychotherapists, with PhD or PsyD degrees and solo practices, were randomly selected from a large health insurance provider's HMO plan. Each received voicemail messages from one purportedly black middle-class and one white middle-class caller of the same gender or from one purportedly black working-class and one white working-class caller of the same gender, requesting an appointment. The callers were evenly divided by race, class, and gender.

Social class was cued through the caller's vocabulary, grammar, and accent, while the caller's name and accent were used to indicate race. All callers requested an appointment, specifying a preference for weekday evenings, and had the same private health insurance coverage.

"It is striking that discrimination toward black and working-class therapy seekers occurred even though all therapy seekers had the same health insurance and were contacting in-network providers," Kugelmass said. "This evidence points to bias rather than financial considerations. It is possible that if insurance coverage had not been held constant, inferences based on racial and class stereotypes would have augmented discrimination even beyond that which was observed."

There were also disparities in the likelihood of receiving a call back from a psychotherapist, but those were less pronounced. Kugelmass found that 51 percent of calls from middle-class whites and 49 percent from middle-class blacks elicited a response, compared to 45 percent for working-class whites and 34 percent for working-class blacks.

"I was surprised that the callback rates were so low," Kugelmass said. "Even the white middle-class therapy seekers received return messages only half of the time. As consumers, or potential consumers, of mental health care, we'd like to think that everyone deserves a response."

According to Kugelmass, even if a psychotherapist ultimately cannot accept a new patient, returning the phone call of a therapy seeker could be a valuable gesture. "If individuals experience a lack of responsiveness during their help-seeking process, they might view reaching out to psychotherapists as a fruitless activity or develop negative attitudes toward a class of professionals that some already regard with skepticism," she said.

Kugelmass also found that the white middle-class woman was favored for the coveted weekday evening appointment; she received an affirmative response to a request for an appointment in that time slot from 16 of 80 therapists (20 percent). By contrast, when the black working-class man made the same request to 80 therapists, only one therapist was willing or able to fulfill the request.

"Psychotherapists are not immune to the stereotypes that influence the decisions of other professionals," Kugelmass said. "Moreover, because therapists in solo private practice have high levels of professional autonomy, they have a lot of latitude to make decisions that are consistent with their biases."

In terms of the study's implications, Kugelmass said her research is evidence of an obstacle to mental health care that cannot be resolved through an expansion of health insurance coverage. "Access to health insurance may not be sufficient to ensure equal access to therapy," she said. "In fact, psychotherapists may unintentionally stymie efforts to promote equal access when they have discretion over their clientele. Macro-level barriers to accessing care are incredibly important, but the influence of interactions between therapists and prospective patients should not be overlooked."